Mental Health Care

Schizophrenia appears to be related to a cluster of causes rather than to a single cause. The current thought is that schizophrenia is a biological disease linked to genetic factors and the imbalance of neurotransmitters (chemicals) in the brain. In some people, the illness could also be caused by abnormalities in the prenatal environment or some distinct structural abnormalities in the brain. The role of stressful life-events has also been a subject of intense study as it is suspected that they could also be playing a secondary part in the precipitation of schizophrenia in vulnerable people.

Genetic Factors

It is clear from the studies of twins, family, and adopted children that genes and schizophrenia are intertwined. The risk of the onset of schizophrenia strongly depends on one’s genetic inheritance. Studies of families with the illness have found that a child who has one parent with schizophrenia, has a 10-13 per cent risk of developing the illness, whereas a child whose mother and father both have schizophrenia is at a 46 per cent risk of being similarly affected. The risk does not mitigate even if such children are adopted and raised by healthy parents. In comparison, children in the general population are only at about one per cent risk. It is likely that not one or two, but many different genes interacting with each other and with environmental risk factors result in schizophrenia.

The Dopamine Factor

There is mounting evidence to suggest that schizophrenia could be a result of an imbalance of chemicals in the brain. These chemicals enable brain cells to communicate with each other and are called neurotransmitters. The main culprit seems to be dopamine. Its overactivity in certain parts of the brain is the likely root cause of schizophrenia. The support for this hypothesis comes from several quarters. First, the effectiveness of antipsychotic drugs, which help in schizophrenia, hinges on blocking receptors for dopamine in the brain. Second, dopamine also plays a role in the mechanisms that govern attention and filtering of stimuli, the breakdown of which can lead to the illness. Third, amphetamines, which increase dopamine activity, intensify psychotic symptoms in people with schizophrenia. Despite these findings, scientists are yet to find out what causes the increase, or increased sensitivity of brain cells to dopamine in the first place.

Structural Abnormalities in the Brain

With the help of newer brain imaging techniques, researchers have discovered specific structural abnormalities in people suffering from schizophrenia. They tend to have larger cerebrospinal fluid cavities in the brain, a smaller overall volume of brain tissue and an abnormally low activity in the frontal lobe of the brain, which governs abstract thought, planning, and judgment. These defects may partially explain the abnormal thoughts, perceptions, and behaviour that characterize schizophrenia. However, these changes are not universal and may also be a result rather than the cause of the illness.

Prenatal Environment

Evidence suggests that pregnant mothers, who have poor nutrition or who get exposed to the influenza virus, are more likely to give birth to a child vulnerable to schizophrenia.

Psychosocial Stress

There has been a search for stressors and possible schizophrenic personality traits that may affect the onset and the course of illness. These efforts have largely drawn a blank, except for finding that stressful life circumstances can trigger episodes of schizophrenia in a person biologically predisposed to the disease. Individuals who have effective skills for managing stress may be less susceptible to its negative effects.

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The illness usually develops slowly over months or years, and can surface at any time. In some people the symptoms may only last for a brief period, disappear, and then appear again in a cyclical fashion for a few years. The illness may then stop recurring and leave no residual effect. This is called the schizophreniform disorder. In most people the disease runs a long and continuous course. The severity of symptoms and the functioning of a person may however wax and wane. The disease may erupt and become severe, but may again become placid. Some people, as they grow older, are fortunate to experience a gradual decline in symptoms. About 25 per cent people with schizophrenia become symptom-free in their later lives.

The illness is marked by a variety of symptoms. The most prominent features are: disordered thinking-thinking becomes incoherent, disjointed and rambling; emotions get unrelated to the situation, actions and utterances become impulsive, and hallucinations overtake-the person begins to hear voices, often of unfriendly kind, or see objects that do not exist. Bizarre delusions is another common feature. The movements may become strange. Most people with schizophrenia cannot recognize that their mental functioning is disturbed or that they need help. They often do not understand that medication is a necessity for them and this worsens their suffering.

To develop a clearer understanding of the illness, let us take a closer look at its characteristic symptoms:

Delusions. Delusions are false ideas or beliefs that obviously appear untrue to other people. People with schizophrenia experience delusions of many kinds and are unable to appreciate why their ideas are unacceptable to those around them. Sometimes, these delusions are extremely grandiose. A person with schizophrenia thus may believe that he is the king, prime minister, or president of a country! Often, the delusions are persecutory in nature. He may believe that people are plotting against him, and are out to get him, or that he is being spied on. This condition is known as paranoia. The delusions may also be bizarre. A person with schizophrenia may thus believe that a stranger has removed his internal organs and has replaced them with someone else’s organs without leaving any wounds or scars. He may also believe that aliens are controlling his thoughts or that his own thoughts are being broadcast to the world so that other people can hear them.

Hallucinations. People with schizophrenia may also experience hallucinations (false sensory perceptions), and may see, hear, smell, feel, or taste things that are not really there. Auditory hallucinations, such as hearing voices when no one else is around, are especially common in schizophrenia. These. hallucinations may include two or more voices conversing with each other, voices that continually comment on the person’s thoughts or behaviour, or voices that command the person to do something. These are fairly characteristic of the illness. These hallucinations must occur when the person is clearly awake and not at the time when he is about to fall asleep or is waking up.

Disorganized Thinking and Speech. Since the thought process gets disorganized in people with schizophrenia, they may talk in an incoherent or nonsensical way and may jump from topic to topic or string together loosely associated phrases. They may also combine words and phrases in meaningless ways or make up new words. In addition, they may show ‘poverty’ of speech, in which they talk less and more slowly than other people, fail to answer questions or reply only briefly, or suddenly stop talking in the middle of a conversation.

Bizarre Behaviour. A person with schizophrenia may behave bizarrely. He may appear markedly dishevelled, may dress in an unusual manner (for example, wear multiple shirts, coats, scarves and gloves or use inappropriate makeup), may talk to himself, may shout or swear without provocation, may walk backward, laugh suddenly without explanation, make funny faces, or may display clearly inappropriate sexual behaviour. In rare cases, he may maintain a rigid, bizarre pose for hours on end, or may engage in constant random or repetitive movements.

Social Withdrawal. A person with schizophrenia may experience several negative symptoms, the most characteristic of them being social withdrawal. The person may thus begin to avoid others or act as though others do not exist. He may show decreased emotional expressiveness, and may talk in a low, monotonous voice, avoid eye contact with others, and display a blank facial expression. He may also have difficulty in experiencing pleasure and may not feel up to taking part in any work or social activities. This lack of volition stops him from initiating and pursuing goal-directed activities.

Other Symptoms. People with schizophrenia may face difficulties with memory, attention span, abstract thinking, and planning ahead. They commonly suffer from anxiety, depression, and suicidal thoughts.

They may experience physical tiredness for no valid reason, may oversleep or find difficulty in sleeping, suffer a loss of sexual interest, become overly dependant, and face problems in money management.

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With the predominant symptoms at the core, schizophrenia has been categorized into five subtypes: paranoid, disorganized (hebe­phrenic), catatonic, undifferentiated, and residual. The first is the paranoid type. Its essential feature is the presence of prominent delusions or auditory hallucinations. Delusions are typically persecutory or grandiose, and hallucinations may also revolve around similar themes. Associated features include anxiety, anger, aloofness and argumentativeness. The person can benefit from treatment and lead an independent life.

The disorganized type is the most severe. It is characterized by silly speech and misplaced laughter, distuption in the ability to perform daily activities, and oddities of behaviour, such as grimacing and other strange mannerisms. The illness has a continuous course without significant letups.

Catatonic illness is marked by waxy flexibility, extreme negativism, rigid or bizarre posturing, parrot-like apparently senseless repetition of a word or phrase just spoken by another person and repetitive imitation of another person’s movements (echopraxia). People with this illness are faced with the risk of becoming malnourished and they may inflict injury on themselves.

The undifferentiated illness features delusions, hallucinations, incoherent speech, disorganized behaviour, or negative symptoms of muted emotion, absence of logic and lack of will to work.

The residual type is characterized by eccentric behaviour, odd beliefs, and mildly disorganized speech. Delusions and hallucinations do not occur or, if present, are mild.

This classification helps in decision-making at the time of treatment and prognosis, but it is not a rigid one. If there is major change in the clinical picture, which happens frequently, the subtype also changes.

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Even though there is no definite cure for schizophrenia, the use of antipsychotic medicines can dramatically improve the quality of life. They can check or eliminate the disturbing symptoms, and allow the person to lead a relatively trouble-free life. With their help, a large majority of people with schizophrenia can return to active social life. They usually, however, need to take medicine for a long time if not for the rest of their lives. This is necessary to prevent a relapse.

There are many antipsychotic medicines which are effective. These include clozapine, risperidone, olanzapine, haloperidol, thioridazine, chlorpromazine, fluphenazine, and trifluoperazine.

Many people with schizophrenia stop taking medicines because they do not understand that they are ill. Some may also have a delusion that the family and the physician are conspiring against them. In that circumstance, the family has to take some difficult decisions. Either the person has to be placed in institutional care, or the family has to take the responsibility of administering the medication. Some antipsychotic medicines are also packaged in liquid form. After due consultation with the physician, they may be given mixed with foods and beverages. This is a difficult ethical issue, although the benefit it holds out for a loved one should make the decision easier.

Some families become careless about the treatment as soon as the person shows improvement. This can undo the good effect of medication and the symptoms can worsen.

However, medication can sometimes lead to unpleasant side effects. Minor side effects include dry mouth, constipation, dizziness, blurred vision and drowsiness. These can often be overcome with some little changes in lifestyle, or by substituting one medicine for another. Difficulty arises when the side effects are more serious and debilitating. These may include muscle spasms or cramps, tremors, and tardive dyskinesia, a condition marked by uncontrollable movements of the lips, mouth and tongue. Newer medications, such as risperidone, clozapine and olanzapine, produce fewer of these side effects, but the search for a better trouble-free medication is still not over.

Some people continue to experience difficulties despite taking medication and may suffer from overriding suicidal thoughts. These people require other types of treatments, including electro-convulsive therapy, to get better. They may have to be committed to institutional care, so that the risk of suicide can be nullified.

Suitable attention should be paid to individual and group psychotherapy, family counseling and vocational rehabilitation in order to maximize the benefits of the treatment and to restore the person to useful public life. Training in social and behavioural skills can help them conduct and manage themselves better.

The Role of the Family

The family of the patient has a major role in the management and the eventual outcome of the illness. Each family member must take part in active counselling. This enables them to develop a proper understanding of the illness and treatment, and they can learn to monitor the progress and create a low-stress environment for the patient.

The family must realize that it is pointless to discuss and debate the logicality of thoughts and actions with the patient. Any attempt at this is likely to complicate matters, simply because the patient lacks insight and cannot be expected to be logical. The situation may become further complicated because of the delusions and hallucinations that occupy the mind of the patient.

The first and foremost duty of the family is to ensure that the patient gets the best possible treatment. If the situation carries risk of self-harm, suitable preventive measures must be initiated. Those people with schizophrenia who express suicidal thoughts require immediate medical attention.

Many families may fail in their duty if they blame themselves and feel guilty for the illness, or simply put the blame on others for it. For this kind of illness, nobody really is at fault. The family should therefore never waste time, effort and resources discussing such trivialities. Rather, they should work cohesively and ensure that the treatment of the patient is not hampered.

The effort must also be geared towards maintaining the patient’s passion for life. The patient must be encouraged to take up the chores of daily living, and when appropriate, suitable responsibilities may be given such that he may find confidence and faith in self and feel that he still has a useful role to play. A home filled with hostility, criticisms, and emotional over-involvement can result in a relapse and affect the outcome adversely.

The family must never disparage the benefits of medication. Many people think that it can be substituted by yoga, meditation, diet, and (or) naturopathy. This belief is misguided. The long-term prospects for people with schizophrenia depend on a family that understands the illness and takes cogent decisions about its management. The illness can be conquered provided the family acts rationally and offers love and care and trust and encouragement to the patient and is ready to raise its own threshold of tolerance.

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Schizophrenia is a devastating mental illness. It imprisons the human consciousness in cobwebs of absurdity. The person loses contact with reality, and the thinking apparatus goes haywire. With thought processes going awry, the mind becomes a prisoner of private fantasies. Emotional expressiveness gets blunted, behaviour becomes odd, actions turn bizarre, the person becomes limited in his or her ability to interact with other people and often withdraws from the outside world.

Of all the mental illnesses, schizophrenia is probably the most difficult to understand for everyone involved. The first signs of illness typically emerge in adolescence or young adulthood. Most people suffer the illness throughout their lives, thereby losing opportunities for careers and relationships. Due to a lack of public understanding about the illness, people with schizophrenia often feel isolated and stigmatized, and are reluctant or unable to talk about their illness. This secretiveness comes as a major shock to families and friends. They feel acutely distressed and confused to see the effects of the illness on their relative, who they remember as being active and lively person before being taken ill. The economic burden and social stigma associated with supporting such a person can also complicate the situation, and family members may try to deny the existence of the illness. Earlier on, this illness was sometimes described as ‘cancer of the mind’ or even ‘living death’ because the person was totally lost to the ‘normal’ world. With modern treatment and management this is no longer true of the majority.

Modern antipsychotic medications can limit its symptoms quite effectively. More than 60 per cent people with schizophrenia can return to normal and lead active fruitful lives. There are a number of people, including some rich and famous and some who have given much to the world, who have flown over the cuckoo’s nest. The famous mathematician, John K Nash, who gave the framework of the Game Theory and received the Nobel prize in 1994, is just one of the many such success stories. In societies where the family network and support is robust, the outcome is even better as the sufferer is not able to totally withdraw into his or her inner fantasy world­the real world never loses its hold on the person.

Strangely though, the name schizophrenia is a misnomer. Its origin goes back to a Greek word which means ’split mind’. However, contrary to the popular belief, a person with schizophrenia does not have split or multiple personalities. Radler, the illness is a disorder of the thinking apparatus. A person with schizophrenia has difficulty in telling the difference between real and unreal experiences, logical and illogical thoughts, and appropriate and inappropriate behaviour. It is as if the electrical circuitry of the brain has gone haywire and wrong or random cross connections result in odd fragmented thinking. These characteristics were first noted by Eugene Bleuler, a Swiss psychiatrist, who wrote a classic paper on the subject, giving the illness its modern name.

Schizophrenia is not a disease of the new age. It merits description in several of the ancient texts, some as old as 1400 BC. The founder of modern psychiatry, German psychiatrist Emil Kraepelin, who devised the first scientific system to identifY and classifY mental disorders, gave it the name of dementia praecox in 1899. Schizophrenia causes an enormous cost to society, both in terms of treatment and lost productivity. Those who suffer from the illness occupy the largest number of beds in psychiatric wards. During an acute phase of the illness they may require hospitalization because of the danger they pose to themselves. Some 40 per cent people with schizophrenia try to commit suicide and 15 per cent end their lives this way. With nobody to take care of them, many people with schizophrenia wander around, homeless. The need in their case is the treatment of the illness, rather than letting them slip away.

One in a Hundred

Schizophrenia affects between one and two per cent of people during their lifetime. The illness is found all across the world. Race and culture do not affect the numbers, and men and women are at equal risk. Whereas most men face the onset of the illness between 16 and 25 years of age, women frequently develop the symptoms between the ages of 25 and 30. There are other differences as well between the two sexes. The illness generally takes a less severe course in women than in men-they need fewer hospitalizations than men, and function better socially in the community.

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